Assisted Vaginal Delivery

Ninth Edition

Copyright 2020© American Academy of Family Physicians. All rights reserved.

 Learning Objectives
• Discuss indications and prerequisites for vacuum and
forceps use
• Discuss pelvic landmarks and define instrument
procedures
• Explain the A through J mnemonic as they apply to
vacuum extraction and forceps assisted delivery
 Introduction
• Assisted vaginal delivery is an important skill for
managing the second stage of labor
• All maternity care providers should have the
knowledge and skills to use a vacuum device or
forceps in emergency situations
 Assisted Vaginal Delivery Rates
• The rate has steadily dropped in the United States from 9.1% of
live births in 1990 to 3.14% of live births in 2015
• Vacuum deliveries now comprise 2.58% of live births
• Forceps deliveries now comprise only 0.56% of live births
• 2007 Survey of US OB/GYN residents: only 50% of seniors felt
competent in the use of forceps, >90% felt competent in the use
of vacuum extractors
Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Drake P. Births: Final Data for 2016. Natl Vital Stat Rep. 2018;67(1):1-55; Powell J, Gilo N,
Foote M, Gil K, Lavin JP. Vacuum and forceps training in residency: experience and self-reported competency. J Perinatol. 2007;27(6):343-346.
 Prevention of Cesarean Delivery
• Assisted vaginal delivery is an important tool to safely prevent
primary cesarean delivery
• Between 3% and 6% of vacuum-assisted vaginal deliveries go
on to cesarean delivery
• Regional differences in vacuum use indicate variable
decision making with a range of 1% to 23% of births across
the United States
Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM. Variation in the rates of operative delivery in the United States. Am J Obstet Gynecol.
2007;196(6):526e1-526e5; O’Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev.
2010;(11):CD005455; Palatnik A, Grobman WA, Hellendag MG, Janetos TM, Gossett DR, Miller ES. Predictors of failed operative vaginal delivery
in a contemporary obstetric cohort. Obstet Gynecol. 2016;127(3):501-506
 Prevention of Cesarean Delivery (Continued)
• Upright or lateral position without epidural analgesia
– Reduces duration of the second stage of labor, but a small
increase in second-degree perineal tears
• Support person associated with a reduction in length of
labor and reduced likelihood of assisted vaginal delivery
• Nulliparous women with epidural analgesia may benefit
from oxytocin augmentation in the second stage of labor
Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst
Rev. 2017;5:CD002006; Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane
Database Syst Rev. 2017;7:CD003766
 Instruments
• Vacuum Extractors
– Historical, rigid metal cup
– Soft plastic cup: instrument of choice in most situations for
the occiput anterior (OA) fetus
– Rigid plastic cup: for occiput posterior (OP) or asynclitism
• Forceps
– Simpson: all-purpose, most suited for large molded head
– Piper, Elliot, Kielland: special indications
 Prolonged Second Stage of Labor
Parity Without With Regional
Regional Anesthetic
Anesthetic
Nullipara 3 hours 4 hours

Multipara 2 hours 3 hours

Cheng YW, Hopkins LM, Caughey AB. How long is too long: Does a prolonged second stage of labor in nulliparous women affect maternal and
neonatal outcomes? Am J Obstet Gynecol. 2004;191(3):933-938
Maternal Indications for Assisted Vaginal
Delivery
• Maternal exhaustion
• Drug-induced analgesia Prolonged second
• Soft tissue resistance with stage of labor
failure to descend
• Maternal illness (eg, cardiorespiratory, intracranial)
 Fetal Indications for Assisted Vaginal
Delivery
• Fetal compromise necessitating immediate delivery
in second stage of labor
• Category III or concerning Category II fetal heart rate
tracings
Assisted Vaginal Delivery Prerequisites
• Vertex presentation, head engaged, position known
• Complete dilatation of cervix
• Rupture of membranes
• No suspected cephalopelvic disproportion
• When shoulder dystocia risk is considered acceptable
• Willingness to abandon procedure
 Fetal Head Engagement
• Passage of the biparietal diameter through pelvic inlet
• Leading edge of fetal skull at or below ischial spines

Copyright 2020© American Academy of Family Physicians. All rights reserved.

Classification of Assisted Vaginal Delivery
• Outlet forceps or vacuum
– Fetal skull at greater than +2 cm from ischial spines
– Fetal skull on pelvic floor, scalp visible between contractions
• Low forceps or vacuum
– Fetal skull +2 cm from ischial spines, but not on pelvic floor
• Mid forceps or vacuum
– Head engaged, but at less than +2 cm from ischial spines
 Vacuum Device
• The preferred assisted vaginal delivery instrument in
the United States and around the world
• Soft bell-shaped cups can minimize maternal and
fetal trauma
• Rigid flat cups can be used for OP position or
asynclitism
Types of Vacuum Devices

Copyright 2020© American Academy of Family Physicians. All rights reserved.

Incidence of Severe Birth Trauma With Assisted
Vaginal Delivery
• Lowest risk – Normal spontaneous vaginal delivery
• Intermediate risk – Delivered with forceps or vacuum alone,
or by cesarean delivery
• Highest risk
– Delivered with combined forceps and vacuum
extraction or
– Delivered by cesarean following failed assisted
vaginal delivery for abnormal fetal heart rate tracing
Alexander JM, et al; The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine
Units Network (MFMU). Failed Operative Vaginal Delivery. Obstet Gynecol. 2009;114(5):1017-1022.
A-J Vacuum-Assisted Delivery Mnemonic
Ask for help
Address the patient
Anesthesia adequate

Bladder empty

Cervix completely dilated

A-J Vacuum-Assisted Delivery Mnemonic
– Determine position
– Anterior fontanel is larger, forms a cross
– Posterior fontanel is smaller, forms a Y
– Bend in ear
– Molding makes an assessment difficult
– Confirm position with ultrasound if possible
– Think shoulder Dystocia
– Prepare for shoulder dystocia
– Cesarean delivery indicated instead of assisted vaginal
delivery if risk is unacceptably high

- Equipment ready
 Flexion Point: Occiput Anterior and
Occiput Posterior Positions

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Note: The placement of the cup is at the identical location on the fetal head. However, in the OP
position, a maneuverable stemmed cup that can be placed lower in the perineum is preferred
Flexed Head Versus Extended Head

Copyright 2020© American Academy of Family Physicians. All rights reserved.

 Insertion of Soft Cup

Copyright 2020© American Academy of Family Physicians. All rights reserved .

A-J Vacuum-Assisted Delivery Mnemonic
- Flexion point placement of
the cup - proper application
results in flexion of fetal head
when traction applied
- Feel for maternal tissue
before and after applying
vacuum

Copyright 2020© American Academy of Family Physicians. All rights reserved .

A-J Vacuum-Assisted Delivery Mnemonic
- Gentle traction at right
angles to plane of cup
- Only during
contractions/with maternal
effort
- Bending or rotary force will
cause detachment and
possible injury
Copyright 2020© American Academy of Family Physicians. All rights reserved.
A-J Vacuum-Assisted Delivery Mnemonic
– Halt traction after contraction
• +/- Reduce pressure between
contractions
– Halt procedure if
• Three disengagements of cup (pop-offs)
• Three contractions with no movement
of fetal head during pulls
• After 20 minutes of total application
– Note that fetal injuries increase at
>10 minutes of application time
– Hold cup with the thumb (index finger on
fetal head)

Copyright 2020© American Academy of Family Physicians. All rights reserved.

A-J Vacuum-Assisted Delivery Mnemonic
- Evaluate for Incision
(episiotomy)
- Not routinely
recommended
- If indicated, mediolateral
approach preferred and
may decrease risk of third-
and fourth-degree
lacerations
- Remove vacuum when
Jaw is reachable Copyright 2020© American Academy of Family Physicians. All rights reserved.
Disadvantages of Vacuum-Assisted
Delivery
• Requires active maternal effort and cooperation
• May take longer than forceps delivery, although
evidence is mixed
• Proper placement and traction are necessary to
avoid losing suction
• Increased risk of cephalohematomas
 Neonatal Complications
• Subgaleal hematoma
– Rare but potentially fatal
• Intracranial hemorrhage
• Retinal hemorrhage
• Scalp laceration
• Jaundice
• Obtaining informed consent is important
• Morbidity may not be prevented with cesarean delivery
 Neonatal Hematomas
Subgaleal Hematoma: Cephalohematoma:
Crosses the suture line Does not cross the suture line

Copyright 2020© American Academy of Family Physicians. All rights reserved.

 Contraindications to Vacuum-Assisted
Vaginal Delivery
• Prematurity (<34 weeks’ gestation)
• Breech, face, or brow presentation
• Transverse lie
• Incomplete cervical dilation
• Head is not engaged; placement above +2 cm station is
considered midpelvic and delivery requires greater skill and
training. An exception is made for a second twin at +1 cm
station, which is appropriate
 Care After Vacuum-Assisted Delivery
• Maternal vaginal and cervical examinations
• Newborn examination for birth trauma
– Caput formation
– Cephalohematoma
– Scalp laceration
– Subgaleal hematoma
– Hyperbilirubinemia
Anatomy of Forceps

Copyright 2020© American Academy of Family Physicians. All rights reserved.

Classifications of Forceps Application

Copyright 2020© American Academy of Family Physicians. All rights reserved.

A-J Forceps-Assisted Vaginal Delivery
Mnemonic
Ask for help
Address the patient
Anesthesia adequate

Bladder empty

Cervix completely dilated

A-J Forceps-Assisted Vaginal Delivery
Mnemonic
Determine position of fetal head
•Confirm with ultrasound if possible
– Think shoulder Dystocia
•Prepare for shoulder dystocia in case it happens
•Cesarean delivery is indicated instead of assisted vaginal delivery
if risk is unacceptably high
– Equipment ready

– Forceps application
 Application of Forceps
• Articulate and hold in position
• Disarticulate, place left blade in left hand
– Apply to left side of woman’s pelvis
– Cephalic curve faces inward toward the vulva to pass around head
– Shank vertical at start
– Pencil grip to avoid excessive force
– Right hand protects maternal tissue, applies force
• Repeat for right side
• Articulate handles and lock
 Application of Forceps

Copyright 2020© American Academy of Family Physicians. All rights reserved.

 Checking Forceps Application
• Position For Safety
– Posterior fontanel midway between shanks, 1 cm above
plane of shanks
– Fenestrations admit no more than one fingertip
– Sutures: lambdoidal above, and equidistant from, upper
surface of each blade; sagittal is midline between blades
A-J Forceps-Assisted Vaginal Delivery Mnemonic
Gentle traction = Pajot maneuver
− Axis traction follows
pelvic curve
− Initial traction downward,
then sweeping in large,
J-shaped arc
− Nondominant hand exerts
downward traction, causing two
vectors of force: horizontal
outward and vertical downward
Copyright 2020© American Academy of Family Physicians. All rights reserved.
A-J Forceps-Assisted Vaginal Delivery Mnemonic
(Continued)

Handle elevated vertically to follow the J-shaped pelvic curve

Copyright 2020© American Academy of Family Physicians. All rights reserved.
A-J Forceps-Assisted Vaginal Delivery Mnemonic

Evaluate for Incision (episiotomy)

−Avoid if possible
−If indicated, mediolateral approach has strongest evidence

Remove forceps when Jaw is reachable

 Assessment After Forceps Delivery
• Maternal examination for cervical and
vaginal lacerations
• Newborn examination for birth trauma
– Fractured clavicle
– Brachial plexus injury
– Cephalohematoma
– Lacerations-abrasions
– Facial nerve palsy
– Forceps marks are normal, benign,
and expected

Copyright 2020© American Academy of Family Physicians. All rights reserved.

Delivery of Occiput Posterior With Forceps
• Attempt manual rotation before/instead of assisted
vaginal delivery
• Kielland forceps rotation, if trained
– Less anal sphincter lacerations than vacuum
• Rigid posterior plastic cup
– More failure than forceps
 Assisted Vaginal Delivery Note
• Preoperative diagnosis
– Estimated fetal weight, position, risk factors, shoulder dystocia
• Postoperative diagnosis
• Operation
• History
• First stage of labor
• Second stage of labor
• Procedure including informed consent
• Number of pulls and pop offs with vacuum
• Third stage of labor
 Summary
• About 3.14% of vaginal deliveries will have assistance
• All maternity care providers should be familiar with
instruments and techniques for their use
• A-J mnemonics provides systematic method for operative
vaginal delivery
• Providers should be aware of complications and
contraindications to these procedures